Nosocomial Meningitis and Bacteremia Due to Contaminated Amphotericin B

Nosocomial Gram-negative bacillary meningitis and bacteremia occurred in a patient who was receiving intrathecal and intravenous amphotericin B. An epidemiologic investigation found the amphotericin B to be contaminated with Enterobacter agglomerans, Pseudomonas fluorescens, and P aeruginosa. These contaminants were traced to a lot ot sodium phosphate buffer that was added to all intrathecal and intravenous amphotericin B preparations. The phosphate buffer underwent prolonged storage at room temperature and was not subject to terminal sterilization nor sterility testing. This parenteral admixture prepared in the hospital is now steam autoclaved and sterility tested before use.